High-tech: Colleague robot, to the OP theatre at once!

17. October 2017

From tumour removal in the head and neck region through to the implantation of reflux pacemakers and prostate biopsies: robots have firmly secured their place in operating rooms. They will become an even greater support for doctors, without however replacing them.

Market researchers predict a bright future for robots in the operating theatre. The report “Surgical Robot Market By Product” established some pictures of the future. By 2024 market volume could multiply six-fold compared to that in 2014. This is due not only to brand-new technologies, but also to the application of already known systems in other areas. Several examples of clinical use show the possibilities that already exist today.

Head and neck tumours: a free hand for operators

Our journey begins in the head and neck area. Transoral laser microsurgery has become the standard procedure for the treatment of tumours worldwide. Despite all the advantages, the surgeons’ view of the surgical area is often restricted. Therefore, several research groups around the world are researching transoral robot-assisted surgery (transoral robotic surgery, or TORS). The surgeon does not hold a scalpel or tweezers directly in the hand, but rather guides these devices using the mechanical arms of the robot. He or she controls the devices with a console while sitting in front of a screen. Live images show the progress of the procedure.

The well-known Da Vinci System is the one most frequently employed. This system does however have some disadvantages: its operating arms have few joints and are quite voluminous. “Accessibility to the tissue, especially in deeper sections of the pharynx, is thereby made more difficult”, Professor Stephan Lang, Director of the Department of Otorhinolaryngology at the Essen University Hospital (Germany), states. He and his colleagues therefore work with a flexible system that has been specially developed for head and neck surgery. Grippers, scissors and other instruments are located in a flexible endoscope, using which the surgeon can pass through constrictions. “Tumours in areas that are particularly difficult to access, such as the base of the tongue or lower pharynx, are able to be seen well and removed”, Lang summarises in recently published experiences. Another positive aspect is “tactile feedback” which is conveyed to the surgeon through the instruments, he says.

Reflux pacemaker placed very specifically

Moving on from the head and neck area, we continue towards the oesophagus. Professor Dr. Gero Puhl from the Department of General, Visceral and Vascular Surgery, Asklepios Kliniken Hamburg, has been treating patients with reflux for years. He has recently installed the first oesophageal pacemaker with the aid of the Da Vinci system.

“At the transition to the oesophagus, two electrodes have to be attached such that there is no risk of them slipping out”, Puhl says. This is normally done through a keyhole operation with rigid instruments, he says. He is enthusiastic about the new system: “The advantages of robot-assisted surgical methods are obvious: the greatest possible precision in a very narrow surgical area, on account of the high magnification and the enormous freedom of movement the instruments have”.

Researchers at TU Darmstadt (Germany) are interested in even deeper lying regions. As part of the DFG-funded project FLEXMIN they are trying to develop robots for the removal of rectal tumours. The aim of their plan is to introduce instruments and a mini camera transanally. “This protects the patient, because dispensing with cutting steps accelerates healing”, Dr Christian Hatzfeld from TU Darmstadt explains.

Previously, surgical robots had their weaknesses in this particular task. They lack what could be described as an acquired sensitivity and feel for knowing where knotted diseased tissue ends and healthy tissue begins. Therefore researchers have developed sensors that give their devices a kind of touch sensitivity. For standard tasks such as the setting of surgical sutures, there are fully automatic programs in existence. Another special feature is the extreme ease of movement, which had not yet been achieved by a robot before this.

Puncturing the prostate with targeted precision

Then we move from the gastrointestinal to the urogenital tract. At University Hospital Leipzig (UKL) (Germany) doctors are working with the first system nationwide, produced by Soteria Medical, for robot-supported prostate puncturing. The Netherland’s University Clinic Radboud is also involved as a technical partner.

“The conventional procedure is relatively complicated, time-consuming and sometimes burdensome for the patient”, says lecturer Dr. Michael Moche from the Clinic and Polyclinic for Diagnostics and interventional Radiology at the UKL. Until now, when working in areas where the tumours were assumed to be located, doctors had to work using a cumbersome targeted manual guidance system. “The patient lies for up to an hour in the MRI, and the second half of the procedure in particular is perceived by many patients as stressful”, according to Moche.

Using the new system the time required is cut in half. The target can be selected directly via images from the MRT. The best access path is chosen automatically with technical precision. Due to its proximity to the MRT, all parts of the new assistance system consist of plastic. They are controlled pneumatically, not electrically.

“The many previous approach steps that took a lot of time fall by the wayside”, Moche reports. “We can now take samples from several lesions one after another much more quickly. However the insertion itself, as previously, is carried out by doctors, and not by the surgical robot.

The doctor’s right hand

Whether we like it or not, the future of medicine lies clearly with the increased use of technological aids. One thing is for sure: robots will not replace doctors, but will support them and free them of some tasks. Experts speak of “assistant intelligence”: the robot as the right hand of the physician.